Elsevier

Journal of Surgical Education

Volume 78, Issue 4, July–August 2021, Pages 1127-1135
Journal of Surgical Education

Original Reports
Readiness of Graduating General Surgery Residents to Perform Colorectal Procedures

https://doi.org/10.1016/j.jsurg.2020.12.015Get rights and content

Objective

In the United States, the majority of colorectal procedures are performed primarily by nonfellowship trained general surgeons. Given that surgical technique and experience affect patient outcomes, it is important that general surgeons are well-trained to perform colorectal surgery operations. In this study, we evaluated how prepared general surgery residents were to perform colorectal procedures upon graduating residency.

Design

This was a retrospective observational cohort study. Attending ratings of residents’ intraoperative performance were collected with the System for Improving and Measuring Procedural Learning application from 9/2015 to 9/2018. Descriptive analyses and Bayesian mixed models were used to determine a resident's probability of being deemed competent upon graduating residency, controlling for core vs. advanced procedure, case complexity, and rater and resident effects.

Setting

Faculty and residents within 30 teaching institutions within the Procedural Learning and Safety Collaborative (PLSC).

Patients

We sampled colorectal procedures and categorized them as core or advanced based on American Board of Surgery designations.

Results

A total of 564 residents were rated after 2102 operations (82% core, 18% advanced). A resident in their fifth year of clinical training had a 93% (95% CI 85-97%) adjusted probability of competent performance after a core procedure and 75% (95% CI 55-89%) after an advanced procedure.

Conclusions

General surgery residents were not universally deemed competent to perform colorectal procedures even at the end of residency. These gaps were more pronounced for advanced colorectal procedures. Current graduation requirements should be carefully reviewed to ensure residents are appropriately trained to meet the needs of their communities. Additionally, advanced training remains a critical resource for surgeons who will perform complex colorectal procedures in practice.

Introduction

Traditionally, the goal of surgical residency has been to prepare residents to practice surgery independently.1,2 However, work hour limitations and expectations of faculty supervision may threaten residents’ maturation in many domains, including technical skill.3 National survey studies find that residents, residency program directors, and fellowship directors have concerns that graduating residents are unprepared to operate without supervision.4, 5, 6 These opinions are corroborated by a previous population-based study that specifically examined residents’ technical performance, as rated by attendings, in general surgery procedures.7 This study analyzed 10,130 ratings of 536 categorical general surgery residents, and found that residents are not universally ready to independently perform procedures defined as “core” by the American Board of Surgery (ABS).8 Perhaps as a result, the majority of general surgery residents choose to enter specialty fellowship training.9, 10, 11, 12

Because the demand for colorectal operations across the US exceeds the supply of fellowship trained colon and rectal surgeons, most of these operations are still performed by general surgeons.13 Population-based studies show that general surgeons perform 69% of anorectal procedures, 77% of proctectomies, 88% of colectomies, and 94% of urgent or emergent colectomies for diverticulitis.14,15 Yet, there are no detailed studies that evaluate general surgery residents’ preparedness in colorectal procedures without fellowship training. It is unknown whether there are differences in level of preparedness between common operations, such as colectomy, and more complicated operations, such as abdominoperineal proctectomy. Quantifying residents’ proficiency in these procedures can identify training gaps and define the necessity for advanced training in colon and rectal surgery.

In this study, we analyzed attending ratings of graduating general surgery residents’ performance and autonomy after a variety of colorectal surgery procedures. Those analyses were done in reference to the ABS taxonomy for surgical procedures, which divides procedures into core (e.g., partial colectomy) and advanced (e.g., abdominoperineal resection, or APR). We hypothesized that resident performance would be rated lower in advanced procedures compared to core procedures. Similarly, we hypothesized that resident autonomy would be rated lower in advanced procedures.

Section snippets

Overview

This study was reviewed by the University of Michigan Institutional Review Board and deemed Not Regulated. We used data from the Procedural Learning and Safety Collaborative (PLSC), a national surgical education quality improvement collaborative that investigates and develops tools to improve surgical learning and training. As part of a multi-institution observational study, the PLSC collected general surgery attending and resident ratings of a resident's technical performance after completing

Subjects and Procedures

This study included 2102 rated colorectal cases for 564 general surgery residents, rated by a total of 306 attendings from September 2015 to September 2018 (Table 3). Residents included this study were from 30 programs; 9 (30%) of these programs had a dedicated colon and rectal surgery residency. Out of the 30 programs, 25 (83%) were university-based, 1 (3%) was a community program, and 4 (13%) were community-based but university-affiliated. The mean (SD) number of residents per class was 7

Discussion

This study had 2 main findings. First, general surgery residents were not universally considered ready to perform colorectal operations independently in the last year of their residency. Second, competency gaps were particularly pronounced for advanced colorectal operations, such as LAR or APR. After adjusting for rater factors and other confounding variables, a graduating general surgery resident had a 93% probability of having competent performance in a core procedure, but only a 75%

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  • Cited by (8)

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    Funding: JVV: National Institute of Diabetes and Digestive and Kidney Diseases, 1F32DK115340-01A1. BCG: University of Michigan Graduate Medical Education Innovations Fund. SJR: National Institutes of Health 5T32DK108740. SER: National Institute on Aging, K08AG047252.

    Disclosures: The authors have no conflicts of interest to report.

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